Yoga and Arthritis of the Hands

by Baxter

Every time I get a call from a student or patient about arthritis of the hands, it brings to mind an image of my beloved Grandma Lopresto, at her towering height of 4’11”, who lived to be 93 with the clearest mind you can imagine. She had arthritis in her hands. Yet I never recall her complaining about it. In fact, I never heard her complain about her body at all, even though she also suffered from post-herpetic neuralgia, a chronic painful condition that is an aftermath of getting shingles. 

But back to Grandma’s hands—when you looked at her hands, she had obvious swelling around the knuckles of almost every finger on both hands. And although I would see her working the fingers by rubbing and bending them, it did not seem to slow her down, as she lived on her own for 29 years after her husband died when she was 64. I can recall her even doing some simple sewing projects to replace a button and such.

Ah, if this were the case for others with arthritis of the hands! For many, there is chronic pain that is disruptive to daily activities, sometimes requiring pain medication, anti-inflammatories, injections and more invasive measures to deal with it. Grandma certainly had classic osteoarthritis of the fingers, which affects the last joint of the finger, the DIP joint, and involves small nodular swelling around the joint known as Heberden’s nodes, and the closer knuckle, the PIP joint, with Bouchard's nodes. The most common site affected by arthritis in the hands, however, is the thumb. It is usually a form of osteoarthritis, the common wear and tear arthritis that affects millions of Americans annually. It affects the joint between the carpal (wrist bones) bones and the metacarpal of the thumb (which resides in the palm of the hand). On its worst days, basal joint arthritis (its other name) can cause pain, swelling, stiffness, weakness or immobility. In addition to what I have mentioned already, treatment by your family doc or rheumatologist can also include self-care recommendations and splints. These splints can help decrease pain, re-align the bones, and permit the joint to rest. Obviously, if you have to wear a splint, you’ll need to modify your hand use in yoga.

One thing to keep in mind is that osteoarthritis often results from trauma or injury to the thumb at some point in the past, and that over time the protective coating of cartilage on the ends of the bones wears away, exposing sensitive bone to bone.  One way to address this via yoga or visualization is to lengthen the thumbs or fingers, depending on which joints are affected, from palm to fingertips, specifically focusing on the affected joint. The encouragement you get from your teacher to spread and lengthen the fingers in poses like Downward-Facing Dog pose is pretty good advice. Although, as you might imagine, you may need to avoid putting full body weight onto your hands if you are experiencing a full-blown joint flare.  In such situations, non-weight bearing asana would be more appropriate, of which there are many.  Ones in which the arms are overhead, such as Warrior 1 and Tree pose, can be particularly helpful to enlist the aid of gravity in pulling swelling away from the hands and back toward the heart. 

Often the pain and stiffness of osteoarthritis in the hands is most noticeable in the morning when you first get up. Warming your joints in the shower and gentle movements of your hands and fingers for 15 to 20 minutes can result in less stiffness and decrease in pain.  If you have not seen a physical therapist for specific range of motion exercises, consider asking to do so. In the meantime, you can use your yoga sessions to put your hands and thumbs through their paces, maximizing the range of motions in the most pain free way you can. 

Other patterns of finger arthritis include the less common condition of rheumatoid arthritis, which affects the hands at the wrist joint and at the joint between the palm bone and the finger bone, the metacarpal-phalageal joint.  Often, more than one joint is involved. Rheumatoid arthritis is an autoimmune illness, and it can cause much worse and more persistent symptoms than osteoarthritis so even gentler approach may be needed.

If you are at risk for developing arthritis in the hands, via age (over 40), sex (female), family history of osteoarthritis or rheumatoid arthritis, or history of trauma to your hands, a balanced yoga practice, with a careful, stepwise approach to yoga poses that involve bearing weight on the hands (such Cat/Cow pose, Downward-Facing Dog pose, Upward-Facing Dog pose, and all arm balances), may be helpful in maintaining a good range of motion in your hand joints over time. Adding a variety of hasta mudras, or hand seals, could exercise and strengthen your fingers in a non-weight bearing fashion.

And for those who have already developed arthritis, less weight-bearing asana is likely the way to go. There are also a number of props coming out that could assist in more pain-free exploration of the asana in which your hands are on the floor.  Specialized gloves with a rubber cushion for the heel of the hand, as well as wedges, rounded blocks, and weird circular cushions called Yoga Jellies are all possible aids to permit careful inclusion of weight-bearing asana in your practice.  And surely, as you must know by now if you are a frequent reader, enlist the help of an experienced teacher who has worked with others who have arthritis!

Benevolence of Spirit

In a Japanese Garden by Brad Gibson

“The practice of yogasana for the sake of health, to keep fit, or to maintain flexibility is the external practice of yoga. While this is a legitimate place to begin, it is not the end… Even in simple asanas, one is experiencing the three levels of quest: the external quest, which brings firmness of the body; the internal quest, which brings steadiness of intelligence; and the innermost quest, which brings benevolence of spirit.” —BKS Iyengar

Planning a Practice for Improving Balance

by Shari

We've had a question about how to practice when you want to work on balance. We're going to take our time addressing this issue because there are several factors involved in balance. When you plan a daily balance practice, it is important to include all six basic balance components:

1.  Strength: Strengthening your legs is critical. Leg muscles that need to be strong for good balance include the quadriceps, hamstrings, adductors, gluteal, and ankle muscles. (Please see Baxter’s recent posts on feet and ankles). In addition, the back muscles specifically the back extensors, are also important.
2. Proprioception: The ability to sense where we are in space is critical for balance. Practicing with an emphasis on proprioception can help maintain or even increase this ability.
3. Central Nervous System Reactivity: The ability to coordinate movements of your eyes is essential to seeing objects in your environment clearly while you are in motion, and other central nervous system reactions help you maintain balance.
4. Postural Control: Standing well is the critical component for maintaining balance.
5. Gait: Varying how fast and slow you walk, as well as the sizes and directions of step, can help you stay more nimble and avoid falling.
6. Vestibular System: The vestibular system is the sensory system that contributes to movement and sense of balance. Together with the cochlea, a part of the auditory system, it constitutes the labyrinth of the inner ear in most mammals, situated in the vestibulum in the inner ear.

You can target your specific “challenge” areas by varying how you incorporate these components in your practice.

Strength

We need dynamic as well as static strength to prevent falling. Simple ways to strengthen your legs can be standing up and down from a standard height chair without using your arms to assist you. How slowly or quickly you do this can add to the variability for the muscles. Holding the position at various points in going down and coming up is also good. Working until your legs feel fatigue is the key to strengthening these muscles. But please remember these types of quadriceps exercises load the knees significantly and they could potentially aggravate an arthritic knee. So be careful.

Another way to build leg strength is a stair-stepping routine of stepping up and down one step with one leg and then changing and doing it on the other leg. You can also side step up and down with one leg as well as back stepping up and down with one leg. Try not to use the handrails unless you absolutely need to. Varying the speed of the step is good, too.

So now to translate this to yoga poses: think Warrior 2, Warrior 1, Extended Side Angle pose (Parvakonasana) and Powerful pose (Utkatasana). Move into and out of these poses first as a flow, pivoting your feet to keep changing directions. Then move into and out of these poses more quickly. Having a friend call out the poses so you can’t anticipate them can be fun—putting together your own sequence to delight your practice buddies! Then working to hold the poses with a timer to build strength. Start with a doable time, for example, ten seconds, and then increase it slowly. Thirty seconds is actually an eternity to hold a pose that is difficult for you. Varying how low you go into a pose is also valuable. Stepping into poses but not taking the actual pose also will challenge your reactions especially if someone else is also calling it out to you.

For back strength (this also includes gluteal muscles), try Locust pose (Salabasana) with arms and legs, as well as an all-fours position with opposite arm and leg lefts (Baxter calls this Hunting Dog pose—see Hunting Dog Pose for complete information on how to do this pose).

For ankles, try lunges with an emphasis on the back foot, toe rises and rocks with no hands (with both legs or one at a time). 
 
Proprioception

Closing your eyes while you practice can help with proprioception. For example, do toe rises and heel rocks but now close your eyes.

You can also work on an unstable surface, such as a foam mat (thick), an inflated air bed, your own bed or a couch (be creative and safe when choosing the unstable surface). Try standing in Tadasana (Mountain pose) with your feet hips-width apart and then with feet together on an unstable surface (first with your eyes open and then closed). After Tadasana, try heel-toe rocks on your unstable surface, first with your eyes open and then closed if possible. If you feel really adventuresome, try some standing poses on this surface, such as Warrior 2, Triangle pose, and Downward-Facing Dog or Hunting Dog pose as shown above. If this is doable, try closing your eyes and doing these poses on an unstable surface. Please make sure that you don’t fall off of whatever you are on because that would really be counterproductive.
 
Central Nervous System

Now let’s add the central nervous system challenge. Standing on an unstable surface, use your eyes to track a moving object. If you are doing this with a friend, he or she can hold a bright object in their hands while you use your eyes to follow their movement in front of you. Do not move your head or body, just use your eyes to track the object’s movement.

Now you can do a dynamic resistive exercise together. Stand facing each other palm to palm with your hands at shoulder height. One person is the leader and the other is the follower. The leader slowly starts to push into the follower’s hands and the follower matches their push into them with an equal push toward them. The leader keeps slowly increasing the force and the follower continues to match it. Then, without warning, the leader with quickly releases the force and move away from the follower. The follower is trying not to fall when the force has been removed. The leader is close enough to steady the follower so they don’t really fall. Change roles and repeat.

Another partner idea is to stand front to front again, but this time one person is holding a light object just out of their partner’s reach. The reacher is trying to lean to grab the object but the partner continues to slowly move the object just out of reach. The reacher cannot move his or her feet but can shift weight or turn without moving his or her feet. High reaching as well as below waist level reaching is good. There will be a point of reach when the reacher will lose his or her balance—that is the whole idea and the person holding the object should be able to assist their partner so no actual fall occurs. Change roles and repeat.

Postural Control

When working on postural control the key is to learn axial (skeletal) elongation as well as peripheral (arm and leg) elongation. The practice of Tadasana (Mountain pose) is difficult because of its simplicity. But learning your own postural habits is something that does affect balance and the ability to right yourself when a fall occurs.

You can address this component with a friend. Get a stick, such as a dowel, that is approximately six feet long and have your friend stand in Tadasana. Place the stick along his or her back body and see how many points of contact there are. Does the back of the head touch the stick? The upper back? The lower back? The buttocks? Do the backs of the knees touch the stick? Then look in an anatomy book to see what ideal posture is. Once you understand what your own issues are, then if you work with a yoga teacher, he or she can help you start to work on those areas that may need some attention.

Another component to address is the ability to safely lift an object off of the floor without falling forward onto your face when doing so. You can try this first with a friend and a light object like a newspaper. Each of you can do the task, which may be easier for some to do than others. Talk with each other to see if you can identify what makes it easy for some of you and more challenging for the others. With this information then you can decide if your personal issues are strength deficits, mobility or flexibility challenges, or other balance issues.

Now back to yoga poses that combine strength proprioception, and posture. Think Tree pose (Vrksasana), Mountain pose (Tadasana), Half Moon pose (Ardha Chandrasana), and Powerful pose (Utkatasana) with eyes open and closed, and with a stable and unstable surface. I am also particularly fond of the all-fours routine (Hunting Dog pose) on an unstable surface with eyes open and closed. Really you could pick one standing pose a week and work it through these variables of changing the surface you practice on, and whether you have your eyes open or closed. Moving into and out of the posture slowly or with variability in the degree of depth of the posture. The choices are endless actually.
 
Gait and Vestibular System

Try varying the speed of your walking—very fast or slow, big steps or small steps, quick changes in directions. You can also try stepping over items and around items, with quick changes again in direction after stepping over objects. Vary the objects you step over; some can be high and some can be low. You could do this with a group of friend, and have one person calling out what to do and the others following the directions. You could add music (like musical chairs) but when the music stops a pose might be called out for you to do.

And then there is what I call the “Queen Elizabeth walk” Walk at a stately pace while waving with alternating hands and turning your head to look at your adoring subject. The idea here is to make your practice fun!